COMPLIANCE INFO_1991-2004 - Laserfiche WebLink

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STATE OF CALIFORNIA STATE WATER RESOURCES CONTROL BOARD DEC Na UNDERGROUND STORAGE TANK PERMIT APPLICATION- FQflk4l priN H PEW COMPLETE A SEPARATE FORM FOR EACH TANK SYSTEM. MARK ONLY 1 NEW PERMIT F7 3 RENEWAL PERMIT F7 5 CHANGE OF INFORMATION ❑ 7 PERMANENTIL LO,-Qb-CnTE ONE ITEM ❑ 2 INTERIM PERMIT F74 AMENDED PERMIT ❑ 6 TEMPORARY TANK CLOSURE ❑ 8 TANK REM�ED DBA OR FACILITY NAME WHERE TANK IS INSTALLED: mel o gwl 11,71A- 1. TANK DESCRIPTION COMPLETE ALL ITEMS- SPECIFY IF UNKNOWN A. OWNER'S TANK I.D.# t+X-. B. MANUFACTURED BY: C. DATE INSTALLED(MO/DAYNEAR) 14 f D. TANK CAPACITY IN GALLONS: ILTANKCTENTS IFA-1 IS MARKED,COMPLETE ITEM C. Vv A. l MOTOR VEHICLE FUEL F74 OIL B. a REGULAR ❑ 3 DIESEL C' 2ri UNLEADED ❑ 6 AVIATION GAS ❑ 2 PETROLEUM ❑ 80 EMPTY ❑ I PRODUCT ❑ lb PREMIUM 4 GASAHOL = UNLEADED 5 JET FUEL ❑ 7 METHANOL ❑ 3 CHEMICAL PRODUCT ❑ 95 UNKNOWN ❑ 2 WASTE ❑ 2 LEADED ❑ 99 OTHER (DESCRIBE IN ITEM D. BELOW) D. IF(A.1)IS NOT MARKED, ENTER NAME OF SUBSTANCE STORED C.A.S.x: 111. TANK CONSTROON MARK ONE ITEM ONLY IN BOXES A.13,AND C.AND ALL THAT APPLIES IN BOX D AND E A. TYPE OF I DOUBLE WALL ❑ 3 SINGLE WALL WITH EXTERIOR LINER ❑ 95 UNKNOWN SYSTEM ❑ 2 SINGLE WALL ❑ 4 SECONDARY CONTAINMENT (VAULTED TANK) ❑ 99 OTHER B. TANK ❑ 1 BARE STEEL ❑ 2 STAINLESS STEEL 21"3 FIBERGLASS ❑ 4 STEEL CLAD W/FIBERGLASS REINFORCED PLASTIC MATERIAL ❑ 5 CONCRETE ❑ 6 POLYVINYL CHLORIDE ❑ 7 ALUMINUM ❑ 8 1009/6 METHANOL COMPATIBLEW/FRIP (Primary Tank) ❑ 9 BRONZE ❑ 10 GALVANIZED STEEL ❑ 95 UNKNOWN ❑ 99 OTHER C.INTERIOR ❑ 1 RUBBER LINED ❑ 2 ALKYD LINING ❑ 3 EPDXY LINING ❑ 4 PHENOLIC LINING LINING ❑ 5 GLASS LINING ❑ 65 UNLINED ❑ 95 UNKNOWN ❑ 99 OTHER IS LINING MATERIAL COMPATIBLE WITH 100% METHANOL? YES— NO— D.CORROSION ❑ 1 POLYETHYLENE WRAP ❑ 2 COATING ❑ 3 VINYL WRAP E74 FIBERGLASS REINFORCED PLASTIC PROTECTION ❑ 5 CATHODIC PROTECTION ❑ 91 NONE ❑ 95 UNKNOWN = 99 OTHER E.SPILL AND OVERFILL SPILL CONTAINMENT INSTALLED(YEAR) OVERFILL PREVENTION EQUIPMENT INSTALLED(YEAR) IV.PIPING INFORMATION CIRCLE A IF ABOVE GROUND OR U IF UNDERGROUND,BOTH IF APPLICABLE A. SYSTEM TYPE A U 1 SUCTION A 67 2 PRESSURE A U 3 GRAVITY A U 99 OTHER B. CONSTRUCTION A U 1 SINGLE WALL Adp 2 DOUBLE WALL A U 3 LINED TRENCH A U 95 UNKNOWN A U 99 OTHER C. MATERIAL AND A U 1 BARE STEEL A U 2 STAINLESS STEEL A U 3 POLYVINYL CHLORIDE(PVC)A 04 FIBERGLASS PIPE CORROSION A U 5 ALUMINUM A U 6 CONCRETE A U 7 STEEL W/COATING A U 8 100% METHANOL COMPATIBLE W/FRP PROTECTION A U 9 GALVANIZED STEEL A U 10 CATHODIC PROTECTION A U 95 UNKNOWN A U 99 OTHER 1 D. LEAK DETECTION �l AUTOMATIC LINE LEAK DETECTOR E2P20 LINE TIGHTNESS TESTINGtIlWil IA MoL IN'NITORING [:] 99 OTHER V.TANK LEAK DETECTION ul 1 VISUAL CHECK 2-12NVENTORY RECONCILIATION [—] 3 VADOZE MONITORING [!�4AUTOMATIC TANK GAUGING 7 5 GROUND WATER MONITORING 6 TANK TESTING �� INVENTORY MONITORING E:l 91 NONE E] 95 UNKNOWN E] 99 OTHER VI.TANK CLOSURE INFORMATION 1.ESTIMATED DATE LAST USED(MO/DAY/YR) 2.ESTIMATED QUANTITY OF 3.WAS TANK FILLED WITH YES �❑ NO ❑ l2ffsl�INING GALLONS INERT MATERIAL? A THIS FORM HAS BEEN COMPLETED UND,--P PENJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT APPLICANT'S NAME [—DATE (PRINTED&SIGNATURE)W,JR I "LIA Z' LOCAL AGENCY USE ONLY THE STATE I.D.NUMBER IS COMPOSED OFTH UR NUMBERS BELOW STATE 04 / L/ COUNTY# JURISDICTION#/ FACILITY# TANK# -;1 0 lo PERMIT NUMBER I PERMIT APPROVED BY/DAT&-..� MIT EXPIRATION DATE FORM 8 (7-91) THIS FORM MUST BE ACCOMPANIED BY A PERMIT APPLICATION-FORM A,UNLESS A CURRENT FORM A HAS BEEN FILED. U L- FOR0034 9-115 ti